Provider Demographics
NPI:1376252601
Name:BASORA, TIARA (LMT)
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:
Last Name:BASORA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1298 MINNESOTA AVE STE E
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-7115
Mailing Address - Country:US
Mailing Address - Phone:352-887-0175
Mailing Address - Fax:
Practice Address - Street 1:1298 MINNESOTA AVE STE E
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-7115
Practice Address - Country:US
Practice Address - Phone:352-887-0175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA98205225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty